Provider Demographics
NPI:1609299064
Name:SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Other - Org Name:SOUTHEASTERN SURGICAL CENTER-2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FORDHAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-671-5026
Mailing Address - Street 1:2002 N CEDAR ST STE B
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3926
Mailing Address - Country:US
Mailing Address - Phone:910-272-3048
Mailing Address - Fax:910-738-3764
Practice Address - Street 1:2934 N ELM ST STE E
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2987
Practice Address - Country:US
Practice Address - Phone:910-739-0022
Practice Address - Fax:910-739-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-21
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0064208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty